Homeowners Quote Form
TX Residents Only

This is a Secure Form
All information will be kept Confidential!

Your Full Name:

Spouse's Full Name:
if applicable-

Address:

City:

County:

State:

Zip Code:

Phone:

Fax:

E-mail (req'd):

Current Insurance Company:

Policy #:

Expiration Date

How Long at This Address:

If Less than 3 years
Previous Address:

Your Date of Birth

Spouse's Date of Birth:
if applicable-

**Your Social Security #:

**Spouse's Social Security #
if applicable-

**A CREDIT AND LOSS REPORT WILL BE OBTAINED AND USED IN THE COMPANY'S DECISION TO ACCEPT OR REJECT THE COVERAGE. BY INPUTTING YOUR SOCIAL SECURITY NUMBER, WE ARE ABLE TO GIVE YOU AN ACCURATE QUOTE.**
PLEASE NOTE: BY INPUTTING YOUR SOCIAL SECURITY NUMBER YOU ARE GIVING TEXAS HILLS INSURANCE PERMISSION TO RUN A CREDIT & LOSS REPORT.

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HOME LOCATION INFORMATION:

Physical Address of Home:

City:

County:

State:

Zip Code:

Is Home:

If OUTSIDE City Limits Please Answer the Following:

Distance to Fire Station:

Water Source:

#of Neighbors Visible

Distance to Fire Hydrant:

Distance from City Limits:

-------- 0-1 mile 2 miles 3 miles 4 miles 5+ miles

Name of Responding Fire Department:

HOME RATING INFORMATION:

Year Home was Built:

Number of Stories:

1 Story 1.5 Stories 2 Stories 2.5 Stories

Total Living Area Square Feet:

Construction:

Frame Brick/Stone Veneer Solid Brick Log

Basement:

no yes

Attached Garage:

no yes if yes, # of cars

Attached Carport:

no yes

Slab or Pier&Beam:

Slab Pier&Beam ------------------

Number of Bathrooms:

1 1.5 2 2.5 3 3.5 4+ .5=1/2 bath

Fireplace:

no yes

Balcony/Deck:

no yes if yes, Approx. sqft.

Approx Sq Ft of Porch:

Roof Material:

composition wood shingle tile metal tar/gravel other

Central Air Conditioning:

no yes

Estimated Value to COMPLETELY REPLACE home in case of a total loss.
(This figure will be used for the amount of insurance on your home)

Please Choose a Deductible:

ANY LOSSES in Past 3 years:

yes no

If YES, Please Provide Details:
(date, type,
amount paid)

Central Alarm-Burglar or Fire/Smoke

Remote Alarm-Burglar or Fire/Smoke

Local Alarm-Burglar Only

Dead Bolts on all doors, Smoke Detectors, Fire Extinguisher

Thank you for completing our online form. We will send you a quote within 5 business days. Please let us know how you would like to send the quote:

E-mail Fax

Please note this is only a quote and does not bind coverage in any way.